A Message to the President: Abortion Can Be Safe, Legal and Still Rare

By Susan A. Cohen

On his first day in office, which coincided with the 28th anniversary of the Roe v. Wade decision legalizing abortion nationwide, President George W. Bush reinstituted the "global gag rule" requiring, among other things, that indigenous nongovernmental organizations overseas, in return for U.S. family planning assistance, promise not to use their own funds to pursue efforts to make abortion legal in their country. His spokesman explained that the president believes this policy will "make abortion more rare."

The notion that the way to minimize women's recourse to abortion is to keep—or, in the U.S. context, make—it illegal is a mainstay of the antiabortion movement. But the argument is belied by the facts. However counterintuitive it may be to some, ample evidence from around the world indicates that there is little correlation between abortion legality and abortion incidence. Instead, utilization of abortion in a given country—whether the procedure is legal or not—is much more closely correlated with levels of unplanned, unwanted pregnancy. The fact is, therefore, that both for individuals and at the program level, the most effective way to reduce abortion is to reduce unintended pregnancy, and the most effective way to do that—since most people inevitably will be sexually active for many years of their life—is to increase access to contraception.

This commonsense conclusion is well supported by the research. Yet, sexual and abortion politics continue to obscure the facts about the relationship between contraception and abortion, and even about effectiveness of contraception itself, leaving room for doubt in the minds of many politicians and some members of the public about the importance of continued U.S. support for family planning services both at home and abroad.

Abortion Laws, Rates and Safety

The main effect of abortion's legal status is not on the likelihood that it will occur but on its safety. In country after country around the world, illegal abortion is associated with women dying and being maimed by unsafe abortion. That was the U.S. experience in the years prior to Roe v. Wade, but in addition to looking back in time, many contemporary—and very stark—examples can be found by simply looking overseas.

For example, abortion is completely illegal throughout Latin America, but abortion rates in Peru, Chile and the Dominican Republic have been estimated to be more than twice the U.S. rate. In Brazil and Colombia, they are substantially higher as well. At the same time, these countries' maternal mortality rates, which are highly associated with unsafe abortion, range from six times to more than 20 times the rate in the United States.

By contrast, in virtually every country in which abortion is legal and also widely available from trained clinicians, abortion-related mortality and morbidity is virtually nonexistent. Moreover, in these countries, abortion rates are by no means necessarily high. Indeed, in some countries in which abortion is not only legal but also very easily accessible to women and even free of charge under a national health insurance system, rates of abortion are among the world's lowest. Countries in this category include the Netherlands, Belgium, Finland and Italy.

The Role of Family Planning

It is clear that for individual women and couples having intercourse, contraceptive use is effective in preventing unintended pregnancy. Research indicates that U.S. women using a method of contraception are only 15% as likely as sexually active women using no method to have an abortion. Put another way, contraception reduces the probability of having an abortion by 85%.

More than nine in 10 U.S. women aged 15-44 who are at risk of unintended pregnancy are using some form of contraception. Rather than using abortion as a method of birth control, then, as opponents of family planning proclaim, virtually all sexually active women are trying to prevent an unintended pregnancy. But contraceptive methods are imperfect, as are the people who use them—so contraceptive failures do occur, resulting in unintended pregnancies. For this reason, just over half of the three million unintended pregnancies in the United States each year occur to the 36 million women who are using contraception. But what is really striking is that almost half of the unintended pregnancies, and almost half of all the abortions annually, occur to the three million women who do not use contraception.

Just as family planning is effective at the individual level, so, too, are organized family planning programs at the country level. The publicly supported program that subsidizes family planning services for low-income and young women in the United States has made significant public health contributions over the last three decades. One of the most important, clearly, is its enormous success in helping women, including young women, to avoid unintended pregnancy (see related article, page 5). In the last two decades, Title X funds alone have been responsible for preventing almost 20 million pregnancies. When all sources of public funding are taken together, the U.S. subsidized family planning program helps women avert some 1.3 million unintended pregnancies, (including 386,000 teenage pregnancies) each year—which if they occurred, would result in approximately 534,000 unintended births, 632,000 abortions and 165,000 miscarriages.

Internationally, in country after country, the introduction of modern methods of contraception is associated with declines in abortion rates. Sometimes, the results are dramatic. This has been especially true in Eastern Europe, where until the early 1990s, modern contraceptives were essentially unavailable and abortion was used as the primary means of birth control.

In Russia, for example, abortion has been legal for a very long time, and at the same time, the intense desire among the Russian people for small families is well established and pervasive. Until very recently, a Russian woman wanting only two children might have had up to 10 abortions in her lifetime. The Russian Ministry of Health estimated that in 1990 only 19% of all married couples were relying on modern contraceptives, but the country had an abortion rate of 109 per 1,000 women of reproductive age (approximately 10 times that of the United States). Only four years later, contraceptive use had risen significantly to 24%, while the abortion rate plummeted to 75 per 1,000 women.

In most countries, however, replacing abortion with contraceptive use takes time. The speed of the decline in abortion rates varies with the rapidity of the increases in access to contraceptives, the effectiveness of the methods chosen and cultural and socioeconomic differences. It also depends in part on the extent to which women previously were relying on abortion—regardless of its legal status—to limit their family size before contraceptive services became available (see box).

Making Abortion Rare

Making Abortion Rare Throughout his campaign for the presidency, President Bush often reiterated his desire to make abortion rare. But he rarely, if ever, took the opportunity to promote family planning as a means of doing so. Instead, he spoke about increasing funds for abstinence education, heightening awareness about adoption, imposing parental consent and other restrictions on access to abortion and helping the American people become "ready" to overturn Roe v. Wade by promoting a "culture of life."

Finally, at virtually the same moment the president was personally announcing his reimposition of the global gag rule, a statement was being issued by the White House press office saying Bush remains committed to overseas family planning funding "because he knows that one of the best ways to prevent abortion is by providing quality voluntary family planning services." The statement was certainly welcome. But so far, the president's action speaks louder than his words.

The gag rule—which prohibits developing country groups that receive U.S. family planning aid from using their own funds to provide counseling about abortion, perform privately funded abortions if they are legal in their country or advocate for abortion law reform if they are not—is not only anti-democratic but also profoundly damaging to the U.S. international family planning program. It is a direct attack on the medical integrity and ethical delivery of family planning care, and at a minimum, it will require the reprogramming of funds away from some of the most effective family planning providers in the world. But while it is certainly anti-family planning, the gag rule is antiabortion in name only. There is ample evidence from which to conclude that in all likelihood, it will have little if any impact on the incidence of abortions in the developing world. Indeed, to the extent that it is successful in curbing the involvement of local reproductive health organizations in country-level debate with the goal of keeping abortion illegal wherever possible, it may only ensure that abortion in these countries remains clandestine and unsafe—and a continuing, direct threat to women's health and lives.

Reducing Abortion Rates Can Take Time

When the desire for small families takes hold in a society, the initial result is often an increase in both contraceptive use and abortion rates. The experiences of South Korea, the United States and Hungary are cases in point.

In South Korea, contraceptives became available and abortion was legal in the 1960s, when smaller families became a cultural norm. Over the next two decades, fertility declined rapidly, from six to less than two children per woman. But the contraception-abortion mix changed dramatically. Initially, the abortion rate went up, to a high of 83 per 1,000 women of reproductive age in 1980s, but then dropped dramatically to roughly half of that today. Over the same period, contraceptive use tripled to 77% of all married women. The country's abortion rate remains relatively high, however, mainly because a sizable number of South Korean women still rely on less effective methods.

Smaller families also became the norm in the United States in the 1960s. Contraceptive use was high, but so were contraceptive failures and the resulting unintended pregnancies and unplanned births—and clandestine abortions. Following the nationwide legalization of abortion in 1973, the U.S. abortion rate increased over the next several years, peaking in 1980 at 29 per 1,000 women; it then began a gradual decline. Starting in 1990, the abortion rate—along with the teenage pregnancy rate and the overall unintended pregnancy rate—has dropped more steeply to the current rate (as of 1997) of 22 per 1,000 women. A number of factors may be contributing to these trends, but one significant correlate is that contraceptive use has increased, especially since 1990; American women also have shifted to more effective methods and are using the methods better.

Hungary provides perhaps the clearest example of the relationship over a 30-year period between contraception and abortion. Data show that having few children was the norm in Hungary from as early as the 1950s and that smaller families were achieved mainly through heavy reliance on abortion. At that time, contraceptive use hovered at about 20%, while the abortion rate was around 70 per 1,000 women. Contraceptives were not introduced in Hungary until the mid-1960s. Because it took some time for contraceptive services to become widely available and for the necessary behavioral and cultural shifts towards pregnancy prevention to take place, abortion rates continued to increase slightly for a short period, reaching a peak of 90 per 1,000 women in the late 1960s. Once this shift took hold, however, and contraceptive use began a steadily upward trajectory to over 69% today, the abortion rate dropped sharply and now stands at about 35 per 1,000 women.